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Notes for remarks by
Mrs. Wendy A. Tadros
Board Member of the Transportation
Safety Board of Canada
To the Empire Club of Canada - Our Collective
Role in Transportation Safety
Toronto, OntarioFebruary 26, 2004

Thank you Mr. President for that kind introduction.

It's only fitting that I speak to you about
our transportation system in a Hotel that owes
its existence to a railway company.

The Royal York Hotel was the ninth property
developed by Canadian Pacific Railway -- a company
whose fortunes were closely tied to our nation's.

CP's first president, Sir William Van Horne,
understood this symbiotic relationship. That's
one reason he described his growth strategy in
the following way:

Sadly, Sir William did not live to see the Hotel's
grand opening in 1929 - but it was, nevertheless,
a fitting tribute to his career.

That's because the Royal York earned the immediate
distinction as the tallest building in the British
Empire.

To be sure, its 28 stories made a mark
on the city's skyline - some would say an exclamation
mark - that declared emphatically Toronto's presence
in Canada and around the world.

Since then, this grand hotel has attracted more
than 40 million guests ; and pumped millions
of dollars into the local economy.

The hotel's origins touch upon a key theme in
Canadian history: our transportation industry
has played a vital role in our national prosperity.

But I'd argue its future contributions will be
more critical.

Globalization demands it.

As the Throne Speech noted:

"Canada is a trading nation.
And a 21st century economy is an economy open
to the world. Canadian goods, services, capital,
people, and knowledge must be able to reach international
markets."

The public and private sectors are focused on
a transportation system that ensures national
prosperity in the new millennium.

Key initiatives include integrated transportation
services with North America and the world; seamless
intermodal links; innovative transportation technology;
competitive rates and services, and so on.

But all these activities would fall - like a
house of cards- if the industry could not fulfill
its public duty of maintaining a safe and sound
transportation system.

It's the prerequisite to participate
in the global economy.

Everyone knows safety cannot be compromised.
And it's a given that government "must maintain
its role as a vigilant watchdog1."

But the private sector's role is often overlooked
and undervalued in advancing safety.

And, ironically, it's the private sector that
sometimes does not appreciate the contributions
it can - and must - make in a world on the move.

This I think can be attributed, in part, to
a misunderstanding of roles.

Our research shows that many industry players
have high regards for the Transportation Safety
Board of Canada. But some are concerned that we're
not proactive enough in the prevention of accidents
or promotion of safety issues2.

There were 541 marine accidents reported
to the TSB in 2003 ... that's comparable to the
1998 - 2002 average of 537. But more importantly,
fatalities reached a 29 year low of 18 ...
down from 34 during the same
five year period.

Furthermore, Canadian aircraft - other than
ultralights - were involved in 297 accidents
in 2003. This represents an 8 percent decline
from the 1998 - 2002 average. There were also
slightly fewer fatalities last year against the
five year average ... 58 fatalities compared
to 65.

These are good numbers. But our work is not
done, as two recent tragedies attest.

On January 14th, a freight train derailed two
intermodal container cars, as it approached a
highway underpass near Whitby. One of the containers
crushed a vehicle on the street below. Two people
died.

Only a few days later, a small plane crashed
in Lake Erie, killing 10 people.

The public has a right to know what happened
with both accidents. And they will. But some want
answers even before all the evidence is gathered
or analysed.

I call this the "CNN effect" because
the demand for new information can sometimes outpace
the supply. When this happens speculation runs
rampant.

As our Executive Director, David Kinsman, wrote
in an opinion piece for the London Free Press: "we
understand the natural inclination to rush to
judgment. But … the TSB will not cut corners,
or rush complex processes. This would not enhance
safety, nor advance the interests of Canada's
traveling public."

"Life is safer than it
has ever been, but we are no longer prepared to
accept any risk in anything we do,"

And if the public thinks the industry players
- regulators, manufacturers, carriers, associations
- are not responding to their safety concerns,
I can assure you, they'll find other ways to influence
practices and policies.

So what must our collective course
be to ensure our ongoing prosperity as well as
maintain public confidence in the transportation
system?

I believe we must be guided by an open and honest
dialogue…and a desire to advocate change.

Dialogue and advocacy: These are the two principles
I'll discuss today. Let me, by way of introduction
to the TSB, explain what these two principles
mean to us.

The TSB

The TSB is an independent body that investigates
accidents with the purpose of advancing safety
... and to report publicly on our investigations.

Our focus is straightforward. We examine what
happened; why it happened; and how we can help
ensure it never happens again.

The TSB takes a systemic approach
to all our investigations. That means if we're
looking at the failure of a single part, we look
beyond what physically happened - to all other
factors at play.

This approach - recognized by safety experts
around the world as the most meaningful - leads
to a detailed understanding of the occurrence
and thorough safety communications.

We don't assign blame. We focus on the safety
deficiencies and bring them to light for regulators
and industry to act upon.

I want to emphasize this last point. As soon
as a deficiency is identified, we immediately
inform industry players involved in the investigation.
It's important to know that we don't wait
for a final report to take action.

That's exactly what we did last year with regards
to our investigation into the collapse of a wooden
bridge in McBride, B.C.

As recent media reports state: The TSB informed
the regulator and CN that it had not addressed
all of the bridge's safety deficiencies. Our investigation
continues.

More times than not our major investigations
do produce recommendations. These too can be deemed
a success if the industry takes swift action.

To be sure, the transportation industry is committed
to the best system in the world. Everyone knows
that accidents bear too many costs and strain
too many resources.

But on occasion the industry and regulators
have been slow to react to recommendations. And,
in some cases, they have failed to implement them
thoroughly.

We now know the crew was unable to control the
speed after the train was set in motion on the
steep descending grade- with a depleted air brake
system and a dynamic brake that was not engaged.

A variety of factors such as a series of inappropriate
train handling decisions and certain railway operating
procedures contributed to the accident.

Over the course of the investigation, senior
management of the railway took an active interest
in the factors at play; and made important policy
and procedural changes to mitigate the risk of
it happening again.

Working with the TSB, these executives initiated
safety enhancements to improve their operations,
training and locomotive design. As a result, our
final report had no recommendations, nor expressed
any safety concerns.

We need this case to be the norm - not the exception.

That's because detailed investigations - by
their very nature - demand ongoing dialogue between
investigators and industry.

Simply put: it's the best way lead
investigators can access the expertise and information
they require to do their job.

To this end, we must commit to a greater focus
on sharing information on studies and recommendations,
accident data, as well as best practices in investigation
techniques and methodologies.

The TSB encourages a company's involvement in
the development of our reports. And we believe
ongoing dialogue is an important part of the process.

That means if a company is involved directly
or indirectly in an accident, we welcome its input
... it's OUR way of testing the theories in the
draft and ensuring we have the facts straight
before making them public.

Let me remind you that our role will always
be to inform the public about what happened and
why it happened - in an impartial and unbiased
way.

Still, we believe our ongoing dialogue will
not interfere with our independence. The key is
to ensure that cooperative activities with industry
groups have more to do with sharing information than sharing
responsibilities.

Advocacy

Dialogue is the first of two principles to fulfill
our collective responsibility in advancing transportation
safety. The second is advocacy. Its aim is to
ensure our efforts take effect.

The successful completion of the Swissair Flight
111 investigation is a case in point.

Its crash into the waters off Peggy's Cove resulted
in the loss of the 229 lives. Determining
the facts about this terrible tragedy was a lengthy
and complex process - more than 4 years to
complete.

One year ago, we reported that a fire started
in a hidden area above the cockpit ceiling. The
fire started from an electrical wire arcing event,
that ignited flammable material on thermal acoustic
insulation blankets.

The fire then spread across the surface of the
insulation blankets, where other flammable materials
ignited.

As a result, the fire intensified, leading to
the deterioration of the cockpit environment,
the loss of some of the aircraft's systems, and
the eventual loss of the aircraft.

Make no mistake, Swissair was a terrible tragedy.
But positive outcomes have been realized. Boeing,
Swissair, Transport Canada, the FAA, the NTSB
and the Airline Pilots Association, all committed
to change.

Twenty-three recommendations came from this
investigation with the first of 14 interim
recommendations issued six months after the accident.

This can be considered a success by anyone's
definition.

To be sure, airline safety has been enhanced.
Important upgrades, for example, have been made
to flammability standards for aircraft materials.

But more work needs to be done. It will take
many years for the airline industry to eliminate
all flammable materials on aircraft.

We're okay with that - it's realistic to factor
in economic realities, and to allow time for technological
advances.

But there are other more immediate steps one
can take to mitigate the risk of fire onboard.
We would like to see the industry adopt an integrated,
comprehensive firefighting strategy for crews.

Operators believe the industry is capable of
developing such a plan, but have been hesitant
to initiate change on their own.

As a result, little progress has been made in
this area, despite the important findings uncovered
during our investigation.

It now falls to regulatory bodies such as Transport
Canada and the Federal Aviation Administration
in the U.S. to institute mandatory policies on
firefighting in order for meaningful change to
come about.

I want to be clear: the Swissair stakeholders
have done a great deal to advance safety through
our investigation.

But advocacy is easier said than done. Two reasons
come to mind.

First, it requires organizations to champion
safety issues in a more proactive way.

We're not dreaming the impossible dream. I've
met with industry leaders who are very active
in addressing safety issues. One railway company
- Burlington Northern Sante Fe - is a case in
point.

This company working with the NTSB in the U.S.,
tracked all outstanding safety recommendations
and set about implementing them. Today, they are
able to report, they've taken action on all of
those concerns.

The second reason why some organizations have
not embraced their advocacy role is because they
still view safety as a cost - not an investment.

Ultimately, it's up to industry leaders to figure
this one out. I can only encourage them to think
hard about the cost/benefits of preventative measures
stemming from our investigations.

We know the benefits of working together on
an investigation. Imagine the impact we could
have, working alongside the industry in every
investigation, to bring about change.

Conclusion

Earlier on I spoke about the investment made
by one railway company in this Hotel. Coincidentally,
the same year of its launch, an executive from
another railway company addressed the Empire Club.

Sir Henry Thornton paid tribute to all those
who had made Canadian National a powerful industry
player.

Thornton said and I quote:

"If the Railway has achieved
any material degree of success it has been due
to that co-operative spirit, that freedom with
which advice is offered, and that unity of effort..."

Co-operative spirit. Unity of effort. These
phrases can also be applied to the enviable track
record Canada has earned in transportation safety.

As our experiences with Field Hill and Swissair
attest, our success is based on our combined efforts
to establish meaningful dialogue and advocate
change.

We need to build upon these efforts. The global
economy demands it and Canadians deserve nothing
less.

Transportation transcends international boundaries … and
lessons learned in one jurisdiction must be
lessons learned by all jurisdictions.

That's why the TSB works closely with ten other
national investigative bodies - including the
National Transportation Safety Board - to "improve
transport safety in each member country by learning
from the experiences of others5."

Its clear: Our industry's expertise is needed
to promote a safe and sound transportation system
in Canada, and around the world.